ANYTOWN 2018 Application

To be eligible to attend ANYTOWN as a delegate, you must be a rising high school junior or senior and you must attend a school in Guilford County or live in Guilford County.

Applicant information

Please select the session of ANYTOWN you wish to attend
*

I am applying for Session I (June 24 - June 29, 2018) I am applying for Session II (July 15 - July 20, 2018) I can attend either session

Full Name
*

First Name Last Name

Grade you will enter in fall of 2018
*

Date of birth
*

-
Month
-
Day Year

Address
*

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Gender (man, woman, transgender man, transgender woman, etc.)
*

High school
*

Graduation year
*

E-mail
*

Home Phone

-
Area Code Phone Number

Cell Phone

-
Area Code Phone Number

T-shirt size
*

Parent/Guardian Information

Parent /Guardian 1 Name
*

First Name Last Name

E-mail
*

Employer

Work Number

-
Area Code Phone Number

Cell Number

-
Area Code Phone Number

Home Number

-
Area Code Phone Number

Parent/Guardian 2 Name

First Name Last Name

E-mail

Employer

Work Number

-
Area Code Phone Number

Cell Number

-
Area Code Phone Number

Home Number

-
Area Code Phone Number

Demographic information

To ensure diversity at ANYTOWN, we ask that you please check any/all of the following that apply to you: (This information is confidential and will be viewed by NCCJ staff only. It will not be used or disclosed for any other purposes.)

Please share additional information about your identity that you would like us to know.

Community Member Endorsement

We ask that each applicant obtain an endorsement from a teacher, counselor, principal, supervisor or clergy. By endorsing the applicant, it is agreed that the applicant is physically, emotionally and mentally capable of participating in ANYTOWN, which challenges students to discuss their experiences with and attitudes about human relations issues.

Please provide the name of a community member that we can contact for an endorsement.

Endorser's Name
*

First Name Last Name

School/Agency
*

Title
*

Phone Number
*

-
Area Code Phone Number

E-mail
*

Tuition, Fees & Tuition Assistance

A $50 NON-REFUNDABLE REGISTRATION FEE IS REQUIRED TO PROCESS YOUR APPLICATION. If NCCJ does not accept your application, your $50 registration fee will be refunded.

In addition to the registration fee, camp tuition is $600. (The actual cost of ANYTOWN is $1,200 per delegate.)

Tuition assistance is available.

A 50% refund of tuition will be made upon written request when a cencellation is made at least three weeks before a session.

A full refund of tuition will be made if cancellation is because of a delegate's illness. A doctor's statement of the delegate's inability to participate must be submitted with the parent's written request. To receive a refund, submit your request before August 1.

No refund will be given for campers who leave sessions early.

Application deadlines:

April 15
: “Early bird” – register and pay in full by this date and we’ll waive your $50 registration fee.

May 20
: Register and pay in full by this date and be entered into a raffle to win $100 off ANYTOWN tuition.

Note:While we encourage you to apply as soon as possible, know that you can still apply after May 20! We accept applications until ANYTOWN is completely full. Please contact our office to see about current availability or to be added to the waiting list.

Tuition assistance deadlines:

Generous need-based tuition assistance is available to all applicants. (Note: these dates only apply if you are requesting tuition assistance.)

April 15:
Priority deadline for tuition assistance.

May 20:
Second round deadline for tuition assistance.

All information provided will be kept confidential. Please remember that the total tuition and registration fee for ANYTOWN 2018 is $650.

Please select one of the following statements regarding financial aid:
*

I am not applying for tuition assistance. I am applying for tuition assistance.

Of the $650 cost of ANYTOWN, I am able to pay

I would like to request tuition assistance in the amount of

In addition to paying my child's tuition, I would like to help NCCJ cover some or all of the actual costs of ANYTOWN ($1,200 per delegate). I would like to make an additional contribution of

By signing below, I verify that I have thoroughly read the information listed in the tuition, fees and tuition assistance section of this application. I give my permission for the young person named above to apply as a delegate for the NCCJ of the Piedmont Triad ANYTOWN 2018 residential program.

Parent/Guardian Signature
*

Date
*

-
Month
-
Day Year

Health History and Medical Release Form

All medical information will be kept strictly confidential.

This section should be completed by a parent or guardian.

Delegate's Name
*

First Name Last Name

Home address (if different from mailing address)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Date of birth
*

-
Month
-
Day Year

Age

Gender (man, woman, transgender man, transgender woman, etc.)
*

Parent/Guardian 1 Name
*

First Name Last Name

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Emergency Number
*

-
Area Code Phone Number

Other Number

-
Area Code Phone Number

Parent/Guardian 2 Name

First Name Last Name

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Emergency Number

-
Area Code Phone Number

Other Number

-
Area Code Phone Number

If Parent/Guardian is not available in case of emergency, please notify:
*

First Name Last Name

Phone Number
*

-
Area Code Phone Number

Relationship

If Parent/Guardian is not available in case of emergency, please notify:
*

First Name Last Name

Phone Number
*

-
Area Code Phone Number

Relationship

Does this delegate have any physical limitations that may restrict participation in program activities?
*

Yes No

If "Yes", please explain:

Is this delegate presently undergoing counseling or therapy?
*

Yes No

If "Yes", please explain:

Has this delegate been exposed to any contagious diseases in the last 6 months (SARS, chicken pox, etc.)?
*

Yes No

If "Yes", please explain:

Will this delegate be taking any required prescription medication during the ANYTOWN week?
*

Yes No

Medication 1

Dosage

Reason for taking

Medication 2

Dosage

Reason for taking

Medication 3

Dosage

Reason for taking

Medication 4

Dosage

Reason for taking

Medication 5

Dosage

Reason for taking

Note: If a delegate is required to take any medication during the ANYTOWN program OR requires emergency intervention medications such as an inhaler or EpiPen, they MUST bring the medication with them. If they do NOT, they will NOT be allowed to board the bus.

Over the Counter Medication Administration

My child may be given the following medications by ANYTOWN medical personnel to alleviate common aches and pains:
*

If you checked "Asthma" above, is an inhaler required to manage the asthma? (Please note, if an inhaler is needed, the delegate MUST bring it with them or they will not be allowed to board the bus.)

Yes No

If you checked "Asthma" above, when was the date of the delegate's last asthma attack?

If you checked "Allergy" above, is an epi-pen required to manage the allergy? (Please note, if an epi-pen is needed, the delegate MUST bring it with them or they will not be allowed to board the bus.)

Yes No

Please list any known allergies (food, medicines, bee stings, etc.)

Please describe reaction and management (medication):

Dietary Restrictions

Food cannot be prepared to order. However, the BRCC staff does try to accomodate our requests to the best of their ability. (BRCC does not have a kosher or halal kitchen.)

Please list any special dietary needs:

Vegetarian Vegan Does not eat dairy products Does not eat pork Other

If "Other" is checked above, please explain:

Health Insurance

Is the delegate covered by medical/health insurance?
*

Yes No

If yes, please provide the name of insurance company:

Phone Number

-
Area Code Phone Number

Group name/number

Policy number

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Permission to Provide Necessary Treatment or Emergency Care

In the event of an accident or illness that requires emergency medical care, I hereby give permission to the attending (licensed) medical personnel to order such medical attention as may be deemed necessary for the health and safety of my child/the child in my care. In the event that I cannot be immediately reached, I hereby give permission to the nearest qualified medical facility to secure and administer treatment, including hospitalization, to my child/the child in my care.

Signature
*

Date
*

-
Month
-
Day Year

Parent/Guardian Authorization

This health history is correct and complete as far as I know, and my child/the child in my care has permission to participate in the program activities except as noted. I also understand that NCCJ of the Piedmont Triad, Inc., its officers, board members, volunteers, agents, employees and licensees cannot be held liable for any health complications or problems that resulted from or were caused by my child's/the child in my care's negligent regard for his/her own health and safety.

Parent/Guardian's initials
*

Delegate Agreement to Abide by Health Restrictions

I understand and agree to abide by the restrictions placed on my activities during this program. I agree not to infringe on the safety of or knowingly cause bodily harm to the others in attendance at ANYTOWN. I also understand that NCCJ of the Piedmont Triad, Inc., its officers, board members, volunteers, agents, employees and licensees cannot be held liable for any health complications or problems that resulted from or were caused by my negligent regard for my own health and safety.